MONMOUTH GASTROENTEROLOGY, LLC A Division of Allied Digestive Health, LLC
1912 Route 35 South, Suite 201 Oakhurst, NJ 07755 (732) 389-5004; FAX (732) 548-7408
Nadeem A. Baig, MD Kenneth Belitsis, MD Thomas C. Fiest, DO Dharmesh H. Kaswala, MD Laleh A. Merikhi, MD Rajiv Uppal, MD
Shannon Khulusi, NP AiIeen Vasquez, NP www.monmouthgastro.com
Patient Interview Form (PIF)
Patient Information
Email Please check one as your preferred email for communications
Contact Preference Cell number Patient Portal Patient declines
HIPAA compliant to specify email
Race Select one or more
White Black or African American
Asian American Indian or
Alaska Native Native Hawaiian or Other Pacific Islander
Other Race
Ethnicity
Unknown Patient declines
to specify Prohibited by state law
Hispanic or Latino
Sex
Not Hispanic or
Latino Patient declines
to specify Prohibited by
state law Unknown
Male
Preferred Language
Female Other Unknown
English Spanish; Patient declines Castilian to specify Allergies
Consent to Import Medication History
I consent to obtaining a history of my medications purchased at pharmacies.
Pharmacy
Name Address Phone
Current Medications
Immunizations
Diagnostic Studies/Tests
Previous Past or Present Medical Conditions Procedures
Social History Occupation:
Marital Status
Single Married Divorced Separated Widowed
Civil Union
Alcohol
Unknown Other
None
Type Quantity Number Frequency Beer Hard Liquor Wine
Caffeine
None
Coffee
Soft Drink Tea Chocolate
Tobacco
Smoking Status Current every
day smoker Current some
day smoker Former smoker Never smoker
Drug Use
Smoker, current status
unknown Light tobacco
smoker Heavy tobacco
smoker Unknown if ever smoked
None
Family Medical History
No knowledge of family history
No family history of ----------- Colon cancer Polyps
Review Of Systems—Please review and check off what applies to you (if none –check off None)
vomiting bleeding anorectal swelling
rectal prolapse anal itching incomplete
fecal evacuation rectal pain Any
structural abnormalities of the upper GI
tract Any inflammatory diseases of the
upper GI tract Cirrhosis or hepatic
insufficiency Known motility disorder Patients who can't tolerate or take PPI
(allergy) Current intractable GERD / Acid reflux
symptoms Any prior gastrointestinal surgery Any
prior bariatric surgery
Consent to Share Data
I consent to having my medical and demographic information shared with other health care entities.
Reminder Preference
I would like to receive preventive care and follow up care reminders.
Yes
Reviewed with
No
Patient
Signature
Parent Guardian Not Present
Signature
Date